Chiropractor Reed Shiraki noticed a change in his patients after Sept. 11.

"People were coming in more tight, more emotional. I could definitely see a trend there," he said.

But what bothered him more was that after Sept. 11, he was seeing fewer patients.

Ninety percent of the people who walk into Shiraki's Kalihi Kai office don't have chiropractic care covered under their health insurance, so they pay for their visits out-of-pocket. The hit to Hawai'i's economy meant fewer people felt they could afford $40 a visit. Shiraki had always held the belief that no patient should ever be turned away for financial reasons, but when his waiting room got emptier, he knew he had to turn that belief into action.

So Shiraki took a leap of faith and instituted an "honor box" system of payment.

"I tell my patients, 'Just look at your own family situation and decide how much you can afford.' "

As they leave the office, Shiraki's patients slip their payment into the box. If they pay in cash, Shiraki has no way of knowing who paid how much.

"It's fine with me. I no longer want to see people go without what they need. Yes, it's a risky way to run a business, but it's never felt more right."

Shiraki has used the honor box for three weeks, and he says it's working. He's seeing clients return who had dropped out of continued care.

"The results have been pretty powerful. A lot of my patients have told me they're really grateful. They get emotional and really tearful. Some of my patients have even scolded me. They tell me I can't stay in business like that. They're worried for me."

Shiraki was worried, too, but upon doing research, he read a quote that gave him courage. "It said, 'You really cannot try the honor box. You have to do it. If you just try it, you'll find reasons to fail. You have to just make it the way you run your practice.' "

The more patients Shiraki sees, the better the system works on the business end. Right now, he's seeing between 25 and 35 patients a day, about the same level as before Sept. 11.

Shiraki is hoping to inspire other health care providers, particularly chiropractors, to offer the honor box system to their patients.

"Sometimes it just takes seeing someone do it first and not fall on their face."

The honor box or "box-in-the-wall" is actually an idea handed down from chiropractors in the '40s and '50s, who also took payment in everything from baked goods to chickens. Shiraki has bartered with a patient who cleaned his office as payment and has received advertising space in exchange for his services. "So far, though," he says, "no chickens."